Supervision & Duty Hours
UI Graduate Medical Education
Pediatric Hematology/Oncology Fellowship Supervision and Duty Hour Policy
Department of Pediatrics
The Pediatric Hematology/Oncology Research Fellowship ensures that it provides appropriate supervision for all fellows, as well as a duty hour schedule and a work environment that optimizes quality patient care, fortifies the educational trajectory of house staff members, and addresses all applicable program requirements. On-call duties are necessary components of the UIHC clinical care systems and educational programs; these duties are managed to ensure adequate periods of rest with appropriate levels of supervision to deliver safe, effective patient care.
The clinical activities of all fellows are supervised by teaching staff and/or more advanced house staff members in such a way as to ensure that fellows assume progressively increasing responsibility according to each fellow's level of education, ability and experience. The teaching staff determines the level of responsibility accorded to each fellow. On-call schedules for teaching staff and more advanced house staff members are structured to ensure supervision is readily available to those on duty.
A. Supervision and Assignment
Every pediatric hematology/oncology patient will have an attending pediatric hematologist/ oncologist assigned who is responsible to assure the excellence of medical care and to supervise and teach subspecialty trainees involved in the care of that patient. All clinical services will be continuously covered by a faculty member who is accessible at any time by means of the pager system. The assignment of subspecialty trainee working hours is dependent upon the nature of the service, e.g., inpatient, outpatient, and laboratory rotations. The requirements of the Pediatric Residency Review Committee (RRC) are followed. The University of Iowa Hospitals and Clinics (UIHC) Policy for Resident Supervision and Duty Hours as required by ACGME institutional guidelines are also adhered to by our subspecialty training program. All current subspecialty trainees will be provided a copy of this guideline. All incoming subspecialty trainees receive a copy as part of their contract as per UIHC guidelines.
The following guidelines have been established to assure the appropriate supervision of subspecialty trainees:
- Inpatient Pediatric Hematology/Oncology Service
All patients admitted to the pediatric hematology/oncology inpatient service are assigned an attending pediatric hematologist/oncologist. The assignment to this pediatric hematologist/ oncologist is made at the time of admission, regardless of the time of day. The subspecialty trainees are instructed to notify the attending pediatric hematologist/oncologist of every admission to the service and make them aware of the condition of all seriously ill children on the service. Daily attending rounds are made by the faculty and subspecialty trainee who remain actively involved in directing patient care.
2. Outpatient Pediatric Hematology/Oncology Service
All patients seen by subspecialty trainees in the outpatient setting are discussed with the attending pediatric hematologist/oncologist covering the outpatient clinic that day. Faculty supervises the care of every one of these patients as well. Outpatient months are recorded as 40 hour work weeks on MedHub.
3. Other Rotations/Electives
Most other rotations are laboratory based or consultative services (e.g., Radiation Oncology, Hematopathology, Coagulation Laboratory, etc.). As such, the subspecialty trainee performs day duty on the specific service. The subspecialty trainee does not take call for these services but is maintained in the pediatric hematology/oncology division call schedule. Laboratory and consultative service rotations are recorded as 40 hour work weeks on MedHub.
Subspecialty trainees monitor their duty hours during research months. These months are recorded as 40 hour work weeks on MedHub. Trainees are expected to maintain appropriate duty hours during research rotation months. The research rotation of each trainee is monitored by her/his research mentor. Trainees maintain a weekly outpatient clinic as well as week-end call once monthly plus one week-night call each week during research rotations. Weekend call requires 4-8 hrs of in house duty plus overnight call from home; weeknight call is also taken from home. The total hours are monitored on MedHub and conform to the Working Hours as outlined below (Sections B through G).
B. Working Hours of Pediatric Hematology/Oncology Subspecialty Trainees
The Pediatric RRC has mandated work hour rules that are provided in the appendix to this section. These include at least one day out of seven when averaged over four weeks without assigned duties; a maximum of 80 hours/week when averaged over four weeks; at least 10 hours off between shifts and call no more frequently than every third night. We have designed a schedule that complies with these rules. These policies on duty hours are presented to and reviewed with the subspecialty trainee at their original orientation to the program, and each subspecialty trainee is provided a manual for subsequent reference. The faculty too is made aware of the expected work hours for the subspecialty trainee at the beginning of the academic year. Every subspecialty trainee has the opportunity to evaluate each rotation and all supervising faculty that they work with via MedHub. This includes the opportunity to comment on the hours worked on that rotation. If problems are noted, the program director can immediately investigate the issues.
C. Subspecialty Trainee Work Hours
Subspecialty trainee work hours will be monitored by the program director, by means of a work hour record on MedHub maintained by the program coordinator. Subspecialty trainees complete random two week work hour forms upon which they record daily hours worked for the given period. This form will be completed randomly twice per year. It is the goal of our program to eventually have all subspecialty trainees' work hours recorded directly into MedHub through use of a PDA provided the subspecialty trainees upon their arrival as a first year trainee.
All subspecialty trainees will report any concerns about work hours directly to the fellowship director or via rotational evaluations solicited at the end of every rotation.
D. Day Duty:
Day duty on the inpatient service is from 0800 to 1700 on weekdays. On weekends, it is generally from 0700 to 1200. In outpatient clinics, duty is from 0730 to 1700.
E. Home Call:
All night call for our program is taken from home. There is always an attending pediatric hematologist/oncologist available on call via the pager system for the subspecialty trainee. Night call is no more frequent than one in every fourth night. The frequency of subspecialty trainees having to physically come to the hospital is 1-2 times per month on average. When a subspecialty trainee does have to physically come to the hospital during a night call, they may request early dismissal the next work day (by 1300) if they determine their fatigue/stress level is high. Such dismissal can only be granted by the program director or, in the absence of the program director, their surrogate.
F. Weekend Call:
Weekend call is no more frequent than one in every four weekends. Subspecialty trainees round on the inpatients with the attending pediatric hematologist/ oncologist and discuss the patients with the resident team. Upon completion of work rounds and documentation, the subspecialty trainee takes the remainder of their weekend call from home.
G. Moonlighting: Available with Program Director approval according to Graduate Medical Education guidelines.
Pediatric Hematology/Oncology demonstrates that the appropriate level of supervision is in place for all patients cared for by all fellows. These levels of supervision include:
- Direct Supervision- The supervising physician is physically present with the fellow and patient.
- Indirect Supervision
i) with direct supervision immediately available - The supervising physician is physically present within the hospital or other site of patient care, and is immediately available to provide direct supervision.
ii) with direct supervision available - The supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision.
The Pediatric Hematology/Oncology Fellowship Training Program tracks and monitors compliance of duty hours using MedHub.
- Maximum Hours of Work per Week: The duty hours of any fellow must be limited to 80 hours per week (or other applicable limit as specified by the appropriate Residency Review Committee (RRC), when averaged over a 4-week period, inclusive of all in-house call activities and any moonlighting activities. Any time spent in the UIHC or at another institution for clinical and academic purposes, related to the fellowship program, both inpatient and outpatient, shall count toward the weekly maximum. Additionally, the weekly maximum shall include time spent for administrative duties related to patient care, the transfer of patient care, scheduled academic activities such as conferences, research related to the program, and any time the fellow spends on-site after being called in to the hospital. Not included in the weekly maximum is time spent outside of UIHC (or outside another institution related to the program's academic purposes) for academic preparation, reading, and studying.
2. Maximum Duty Period Length:
Any fellow exceeding maximum duty period lengths will document their justification in MedHub and have it approved by the fellowship director.
3. Mandatory Time Free of Duty: Fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). This day off shall not include home call nor shall the fellow be required to carry a pager. A day is defined as 24 consecutive hours.
4. Minimum Time Off between Scheduled Duty Periods
- Fellows (as defined by the program's RRC) - should have 10 hours, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 continuous hours of in-house duty.
- Final year fellows (as defined by the program's RRC) - can participate in transition to practice activities when they are preparing to care for patients over irregular or extended periods. It is still desirable that these fellows have 8 hours free of duty between scheduled duty periods, but there may be circumstances where fellows must stay on duty to care for their patients or return to the hospital after shorter intervals.
- The Program Director monitors time off between scheduled duty periods.
5. Home call: Fellows returning to the hospital from home call must count their time spent in the hospital towards the 80-hour maximum weekly hour limit. The frequency of home call is not subject to the every-third-night limitation but must satisfy the requirement for 1 day in 7 free of duty, when averaged over 4 weeks.
- Home call activities must not be so frequent as to preclude rest and reasonable personal time for each fellow.
- Fellows are permitted to return to the hospital while on home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new "off-duty period."
6. Moonlighting: Moonlighting is governed by the Moonlighting Policy and Procedures for House Staff Physicians and Dentists. All requirements of that policy must also be followed, including visa and license requirements.
- Moonlighting is never required and must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program.
- The fellow must obtain permission of his/her Program Director prior to the beginning of such activities. All approved requests must be filed with the GME Office.
- Time spent by fellows in internal and external moonlighting must be counted toward the 80-hour maximum weekly hour limit. Failure to completely document all time in moonlighting activities will result in suspension of the moonlighting privilege.
The Pediatric Hematology/Oncology Fellowship Training Program meets the requirements of this policy as well as any applicable standard set by the ACGME, the appropriate RRC, or other accrediting or certifying body. This policy is distributed by the GME Office to the Program's GME employment contract holders as well as being placed in the fellow's personal notebook.